Page 1 of 2 INFINFB3743/RevC/01JUN2018 Go-Go Elite Traveller ® - 3 and 4 Wheel Scooter Quick Ship Order Form Pride ® Mobility Products Corporation 182 Susquehanna Ave Exeter, PA 18643 Phone: 800-800-8586 | Fax: 800-800-1636 | Email: [email protected] Account Number: ___________ Date: ________________ Provider Name: __________________________________ Contact: ________________________________________ Phone: ___________________ Fax: _________________ Email:__________________________________________ PO Number:_____________________________________ Marked for: _____________________________________ Ship to Address: _________________________________ City: _____________________ State: ______ Zip: ______ ACCESSORIES Optional. Micro, Black, Weather Cover ............................................. $114 Part: ACCCOVR1020 Rear View Mirror .................................................................. $25 Part: ACC134496 Cup Holder ............................................................................ $20 Part: ACCASMB2288 50" Lap Belt ................................................................ Standard Part: ACCBELT1000 Safety Flag ............................................................................ $38 Part: ACCASMB2079 Saddle Bag (12.5" x 9.875") ................................................ $35 Part: DWR1020D010 Under Seat Storage ............................................................. $80 Part: ACC160129 MODEL REQUIRED. 300 lb. weight capacity. More details and specifications at found at pridemobility.com/scooters. Go-Go Elite Traveller, 3-Wheel...................................... $1,499 Part: SC40E. HCPCS: K0800 - Group 1/Standard Go-Go Elite Traveller, 4-Wheel..................................... $1,599 Part: SC44E. HCPCS: K0800 - Group 1/Standard Includes standard options: • Red, Blue shroud panels • 2-Amp off-board charger • Front Basket • Flat-free tires • Foldable, Molded plastic seat (17"W x 17"D) • Removable Footboard Basket (4-wheel Models Only) BATTERY BOX SELECTION REQUIRED. 12Ah Battery Box ....................................................... Standard Includes two 12Ah Batteries Part: BATASMB1028 18Ah Battery Box ...............................................................$150 Includes two 18Ah Batteries Part: BATASMB1029 This form is interactive when viewed in Adobe Acrobat Reader and may not function correctly if opened with applications other than Acrobat. HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers are responsible for determining the appropriate billing codes when submitting for insurance reimbursement. Payer coding, coverage, and bundling guidelines may apply. All prices are MSRP. Prices, specifications, part numbers, and availability are subject to change without notice. Prices and part numbers as shown are only available when configured as a complete scooter. Please contact technical service for accurate parts ordering. Thank you for choosing Pride Mobility Products! INTRODUCTION